Editorial articles

Physicians use tests to inform decision-making. Whether this is a bedside test using a stethoscope, the seemingly ancient technology of recording an electrocardiogram (ECG), or the most advanced imaging modalities and biochemical panels available – all pursue diagnostic clarity. But, more frequently than we might like to admit, the results do not illuminate a clear path of treatment.

We believe that controlled systemic hypertension should be considered as an important clinical entity (figure 1). We know that cardiovascular risks increase with rising blood pressure, each 2 mmHg increase in systolic blood pressure is associated with a 7% and 10% rise in mortality from ischaemic heart disease and stroke, respectively.¹ However, the converse proposition would also seem to be true. Meta-analyses have found significant reductions in stroke and coronary events associated with blood pressure control,² even in grade 1 hypertension. Furthermore, large studies such as SPRINT (Systolic Blood Pressure Intervention Trial)³ have shown that patients with tighter blood pressure control (mean systolic 121.4 mmHg) have significantly lower rates of major cardiovascular events and heart failure in addition to reduced mortality compared with the standard therapy cohort (mean systolic 136.2 mmHg). With reduction of blood pressure the associated risks are reduced.

Hypertension is a significant problem, both in the general population and among pregnant women, with around one in 10 women experiencing a form of hypertensive disorder during pregnancy.¹ It is the third most common direct cause of maternal mortality worldwide, after haemorrhage and infection,² and is also associated with adverse affects to the baby, including intrauterine growth retardation, premature delivery and respiratory distress syndrome.³

Atrial fibrillation (AF) is known to increase stroke risk and can be stratified clinically by the CHA₂DS₂-VASc scoring system, which then informs recommendations for long-term anticoagulation. Susceptibility to thromboembolism is also increased around the time of catheter ablation of AF. Mechanistically, this is accounted for by endothelial injury, hypercoagulability due to contact of blood with foreign surfaces and altered blood flow after conversion to normal sinus rhythm (figure 1).¹ The risk of stroke persists post-ablation, even in patients with low CHA₂DS₂-VASc scores, as the atria may remain stunned for several weeks post-ablation, and the endothelium takes time to heal. This phenomenon forms the rationale for guidelines currently recommending anticoagulation for two to three months post-ablation.² 

In troubled times, in a sea of uncertainty, it is easy to forget that the UK remains the envy of the world in one aspect at least: the delivery of a national health service (NHS). The structure and organisation of UK general practice; the existence and authority of the National Institute for Health and Care Excellence (NICE) – with national guidance and local dissemination and structured implementation – remain the envy of the world. While our European neighbours stand by holding each other’s coats as Brexit rumbles on, we forget that each of these nations gazes at our health service and wishes they had one just like ours.

Hypertension remains a significant burden on mortality and morbidity, contributing to increasing costs to healthcare provision globally. There is detailed evidence-based guidance on the diagnosis and treatment of hypertension in the community, however, during the peri-operative period for elective surgery, consideration of an elevated blood pressure remains a conundrum. This is a consequence of paucity of evidence, particularly around specific blood pressure cut-offs deemed to be clinically safe. Postponement of planned surgical procedures due to elevated blood pressure is a common reason to cancel necessary surgery. A sprint audit of 11 West London Hospitals with national audit data indicated that the number of cancellations was 1–3%, equating to approximately 100 cancellations per day in the UK.¹ This suggests that approximately 39,730 patients per year may have had a cancellation of a surgical procedure owing to a finding of pre-operative hypertension.² The Association of Anaesthetists of Great Britain and Ireland (AAGBI) together with the British Hypertension Society (BHS) recognise the need for a nationally agreed policy statement on how to deal with raised blood pressure in the pre-operative period and have jointly published guidelines titled: “The measurement of adult blood pressure and management of hypertension before elective surgery” in the journal Anaesthesia.²

The promotion of exercise as a positive and powerful health intervention has never been more important, when consideration is given to the global epidemic of disease states related to a sedentary lifestyle. However, intensive exercise may be a trigger for sudden cardiac death in individuals harbouring quiescent cardiovascular diseases. Indeed, hereditary and congenital abnormalities of the heart are the most common cause of non-traumatic death during sport in young athletes.¹ 

Following Brexit, like many other people with Irish parents, I started the process of applying for an Irish passport. The Irish embassy website informed me, to my surprise, that I had become an Irish citizen on the day I was born. Despite that status, and despite owning a home in County Kerry, I have to admit I know very little about the Irish healthcare system. In fact, having worked my entire life in English healthcare, I do not fully understand the systems in the other three constituent countries of the UK either. My career has mostly involved both primary and secondary care, so I do understand the issues and difficulties of communication between hospitals and general practitioners (GPs).

Ischaemic heart disease (IHD) is the leading cause of mortality worldwide.¹ It is a debilitating, life-changing illness that can reduce quality of life and life-expectancy. While surgical, percutaneous and optimal medical interventions can significantly improve the clinical course of the disease, our understanding of the biopsychosocial mechanisms promoting survival following an acute IHD event, such as an acute coronary syndrome (ACS), is still limited. 

Over and over we hear the message that healthcare spending is out of control, the National Health Service (NHS) needs to save £20 billion and that is before the baby boom* generation fully enters the most expensive part of their healthcare journey…